HIV and AIDS: The Global Inter-Connection

 THE ECONOMICS OF HIV TRANSMISSION

By Deborah K. Raditapole

Migration and widespread population displacement in Lesotho are conditions which enable the spread of HIV and significantly increase the risk to women of contracting the virus. Poor economies in the frontline States compel many young, able-bodied men to seek employment in South Africa. Migrant labour has become the mainstay of that country's mining industry and a critical component of its labour market.

Mobility, for example, in the movements of people along major trade routes plays a key role in the spread of HIV. The migrant labour system of South Africa involves the mobilization of hundreds of thousands of men from throughout the Frontline States. In 1986, approximately 2.6 million workers were officially registered as migrants from areas within South Africa, excluding the independent homelands. An additional 378,000 foreign migrants are nationals of Lesotho, Mozambique, Malawi, Botswana, Swaziland, Zimbabwe, and Zambia.

Migrants throughout the world suffer the stigmatization of their host country's population, but this sense of otherness is heightened by the political and social conditions that exists in South Africa. They live apart from their families and traditional communities, in a racially polarized society, within confined living conditions. In this environment, feelings of isolation and loneliness increase, social constraints tend to diminish, and sex often becomes a source of escape and temporary solace.

In 1986, the South African government began random testing of miners for HIV. There was a high incidence of HIV among the Malawian mine workers and the Government repatriated all Malawians who tested positive. The government stated that they believed the mass repatriation would slow down the spread of the disease. The miners, however, believed that the South African government was merely using HIV as an excuse to limit their numbers.

Forty per cent of South Africa's approximately 750,000 miners are foreign migrants and the majority of them come from Lesotho. More than half of Lesotho's male working population are registered as migrant workers in South Africa and many of these men are married. The majority spend an average of fifteen working years away from home and nearly a third spend between seventeen and twenty-five years of their lives in the mines. But many leave and never return. They either die in the mines, are killed amidst the violence that erupts in the camps, or they simply start new families in the neighboring areas.

In Lesotho and throughout Southern Africa, the migrant labour system encourages relationships which enable the contraction and transmission of HIV. Miners live in poverty in crowded singles hostels removed from family, culture, and community. Long separations strain marriages, leaving both men and women more open to extramarital relations. The sex industry in Southern Africa is very accessible in the border towns that miners travel through, where drinking, gambling and sex serve as outlets to release tension or simply while away the time.

With so many men outside of the country, Lesotho now has a population made up of women, children, the elderly and a few men, often ill or incapacitated as a result of their prior employment in the mines.

The Government of Lesotho has become dependent on the easy and steady revenue received through the remittances of the migrant mine workers. Their absence also reduces the pressure on the government to seriously address the issue of job creation at home. Lesotho's dependence on the income from migrant labour undermines its drive to develop alternative economic solutions.

Another outcome of the current labour system is that investment shemes in Lesotho which require significant numbers of workers often must import labour from neighboring countries. These men, from as far north as Malawi and Zambia, also leave wives and families behind. Often these schemes are located in disadvantaged and poor mountainous areas of the country where the lack of employment has encouraged young men to leave for long periods of time for jobs as miners. These conditions have combined to institutionalize a geographic network of relationships that facilitate the spread of HIV.

Given the high prevalence of sexually transmitted infections, the numbers of migrant mine workers, and the simultaneous increase of HIV infection in neighboring countries, it is likely that Lesotho will experience a dramatic rise in the occurrence of HIV as compared to what has been reported by the Government to date.

Effective education and prevention programmes are desperately needed for migrant workers. Not only must their suspicions and doubts about the epidemic be overcome but, in addition to providing information and addressing individual behaviour, attention must be paid to the conditions that foster so much of the behaviour that puts people at risk.

The risk to women is evident to many miners' wives who are aware that their husbands' behaviour exposes them to HIV. These women are voicing concern about men who use commercial sex workers and the unsafe sexual practices which occur in the all-male singles hostels.

Left to shoulder the responsibility of raising children and cultivating crops, women are subject to oppressive cultural and traditional practices that leave them vulnerable to many forms of abuse. In Lesotho, women are still governed in most aspects of their lives by customary law, under which they are regarded as perpetual minors, subservient to their parent's authority until they marry, and to their husband's authority thereafter. In his absence, control passes to the in-laws and remains with them if he dies. A husband has complete authority over his wife and may punish her as he sees fit. Wife-beating is regarded within the culture as a disciplinary measure, not as a crime.

Having sex with her husband is considered a wife's duty, even in situations where a woman, knowing that her husband has other partners, wishes to protect herself. If she insists that he use a condom or refuses to have sex with him, she may be beaten or abandoned. Even if a woman suspects her spouse may have been exposed to HIV, she has nowhere to turn for support and there are no laws to protect her.

In Lesotho, women's survival options are limited even under the best of circumstances. The girl who gets pregnant as a school girl is denied all chances of advancement. She is discriminated against by society and loses her self esteem. Here, as in other countries, women benefit least from national social services. As a result their poor education and scarce work opportunities allow few choices for survival. Usually widows in Lesotho turn to making and selling the local alcoholic brew to survive. Sex work, which is legal, becomes the only means of subsistence for many women. Some turn to sex work as a means of augmenting existing income because standard wages, which are usually lower than men's wages, are generally insufficient for their needs.

Our society condemns women for engaging in commercial sex work but at the same time it neglects and ignores the economic, social, and cultural factors that encourage this activity. Many miner's wives are widowed at a young age and left with children to support. Culture does not provide room for a widow to remarry, thus sex work may be the sole option for women to earn income to support their families. Lesotho's discriminatory laws also restrict women's choices and access to income thus limiting their options for survival.

Many women believe that miners should be given homes where they could live with their families. While this is an ideal situation, the process of its acceptance and implementation is dependent on the political system in South Africa. Poor Lesotho women have very little, if any, direct influence on politics at home or in South Africa. They would rather cry out for the creation of jobs in Lesotho and thus decrease dependence on jobs in the mines.

Women are also likely to contract HIV from contaminated blood because they are exposed to the country's unsafe blood supply more often than men. This is especially true for malnourished, anaemic women who receive transfusions after childbirth.

During delivery, women who are infected with HIV pose a risk to the traditional birth attendants who assist in 40 to 60 per cent of all home births. These attendants, mostly rural women whose hands and bodies are often scratched, cut and scraped from manual labour, have limited, if any, access to rubber gloves.

There are many reasons why our society and our government must begin to address the impact of HIV on women. A significant increase in HIV infection among women would deal a severe blow to both social and economic development in Lesotho. In addition to providing food and shelter for their families, women's labour substantially contributes to the construction of roads, schools, and clinics. They also make up the majority of primary school teachers and workers in the healthcare professions.

As caretakers of the family, women provide the first level of healthcare as well as moral and psychological support in times of illness. It is apparent as the HIV epidemic spreads that even greater demands are being placed on women. They now have the additional physical and psychological burden of attending to men who have become ill and return home to their villages to die. So far, little attention has been paid to issue of caregivers for women and their dependants as they become ill.

With women functioning as the heads of households in a majority of homes, many children will become parentless as their mothers die of HIV-related illnesses. At present these children are cared for by the extended family. As their numbers increase it will become more apparent that the government has no institutions in place that address the needs of these children. The government will need outside investment of significant financial and human resources to cope with this aspect of the epidemic.

Despite the crucial role of women in Lesotho society, they are routinely stripped of their self confidence. They have been so weakened by the system that they do not know how to organize themselves into effective pressure groups to fight for their rights. Now, more than ever, we must encourage women's self-confidence to enable them to actively effect the changes which will meet their needs. This mobilization must begin in families, schools, churches, and communities. Young girls should be taught that they have a contribution to make to society and that they must take control of their lives.

HIV transmission cannot be controlled and reduced by information, education, and change of sexual behaviour alone. It is necessary to address the socio-economic and political conditions which enable the spread of the epidemic. Rather than focus on and sometimes condemn individual behaviour, our strategy must place sexual behaviour in its social context. The economic culture spurred by the migrant labour system has removed much of our population from the safety of extended family and community support and replaced this with nothing.

Most of our education and prevention programmes are modeled on Western standards and are either poorly conceived or else they are culturally unacceptable or inapplicable. For intervention programmes to be successful, there is an urgent need to address potentially dangerous cultural practices in a manner that takes cultural norms into consideration. For example, in Lesotho it is unacceptable for young women to speak about sexual issues with men, yet most of our nurses and health educators are young women. Special effort must also be made to reach and involve our elders because their word carries weight within the community.

We must move away from the language of crisis and catastrophe that has permeated the discussion of HIV. People change their attitudes and behaviour not because they have received frightening information, but rather through positive messages that offer hope. We need to develop material that emphasizes hope rather than hopelessness.

Most of Lesotho's population is Christian but we have not fully utilized the church's influence on our society. Many of us still see HIV as God's punishment for sins committed, thus showing very little sympathy. The church can help to eliminate many of the myths surrounding HIV. Will HIV have to reach epidemic proportions before people own up to it?

Women are our greatest resource and the church, which is in a strong position to lead in informing and educating society about HIV, should come forward in support of women. It must champion women's cries for job creation and other social and economic changes that will encourage family stability. Who is there to listen to the silent cries of these women and wives? Often their unheard voices go unrecognized within our communities.

It is critical that government review and address the conditions that seriously discriminate against women. Conditions that reduce women to mere commodities, diminish their self-esteem, and foster an environment that increases their risk of infection. This is an issue of human rights and laws must be changed and new legislation introduced in support of these rights.

We must work to control migrant workers' abandonment of families even if the government does not believe there is an urgent need to create more jobs at home or to change migration policy. The legal system, which still regards women as minors with little or no recourse to the law, must be restructured to minimize women's risk of contracting HIV. Efforts must be made to inform and educate women about laws that can help them, especially as they relate to marriage or abuse. Ethical and operational issues should be reexamined to take into account women's social and economic vulnerabilities.

The intervention strategies of existing and future HIV control programmes need to recognize the unique situation of women and children. Empathy should be the key word. If women's concerns are not recognized and they are not incorporated into our HIV prevention programmes, we will lose our strongest ally and hope for success as we face this challenge.

Biographical note

Deborah K. Raditapole is a Minister of Health and Social Welfare in Lesotho. Previously, she was a pharmacologist and managing director of Materia Medica (Pty.) Ltd., a Lesotho-based company providing consultancy services in health and drug-supply management.